Healthcare Provider Details

I. General information

NPI: 1487646279
Provider Name (Legal Business Name): MOUNTAIN MENTAL HEALTH GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 SCHUYLER ST
BOONVILLE NY
13309-1005
US

IV. Provider business mailing address

PO BOX 211
BOONVILLE NY
13309-0211
US

V. Phone/Fax

Practice location:
  • Phone: 315-942-4252
  • Fax: 315-942-3207
Mailing address:
  • Phone: 315-942-4252
  • Fax: 315-942-3207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: BARBARA RICE
Title or Position: GENERAL PARTNER
Credential: LCSW
Phone: 315-942-4252